There When You Need It? the Attack on Health Care Continues

insight: the latest attack • fixing medicare• advocating for seniors analysis: medicare's origins • lrb in wonderland • health care around the world

spring 2009 • • • • insight & analysis U nan alberta federationi o of labour publicationn

There When You Need It? the attack on health care continues

spring 2009 | union 3 contents spring 2009 credits

This issue's contributors 1 First Thoughts | gil mcgowan david eggen • jason foster samara jones • tom fuller feature articles jim selby • michelle westgeest art director 2 The Stealth Attack On robert andruchow Health Care in Alberta VisCom Design david eggen, Executive Director, Friends of Medicare www.viscom.ca design + illustration 7 Fixing Medicare kathleen jacques Picking The Right Mechanic jason foster Union is a seasonal publication of the Alberta Federation of Labour 12 Fighting For Good Care (AFL). It is a magazine intended Interview with Lynda Jonson, seniors’ advocate and activist to provide insight and analysis samara jones into ongoing social, economic and political issues of concern to union burning issue activists, officers and staff. The 16 Cure for “Superbugs”? Clean Hospitals! AFL is Alberta’s largest central tom fuller labour body representing more than 137,000 Alberta workers and labour law their families. 19 Labour Relations Nonsense Labour Law Through the Looking Glass Union is published three times a michelle westgeest year (spring, fall, winter) in elec- tronic and paper versions. international It is distributed free of charge 23 Is Health Care Better Elsewhere? to subscribers. Subscription samara jones requests can be made online at www.afl.org or by contacting history the AFL office. Union is edited 26 Overview Of Canada’s Medicare System collectively by the senior staff at jim selby the Alberta Federation of Labour.

alberta federation of labour 10654–101 Street Edmonton, AB T5H 2S1 Phone: (780)483-3021 Toll Free: 1-800-661-3995 Fax: (780)484-5928 Email: [email protected] First Thoughts this issue’s theme: s it just me or does seem that every three years or so Albertans have to beat backI another Tory attempt to privatize our health- care system? No, that perception is correct The Ongoing Attack on Medicare – they have made repeated attempts to privatize, despite Alber- Canadians believe so strongly in public health care that tans’ insistence that they stop. it has become part of our identity. In our minds it is what sets us apart from the Americans. The real picture We hate to have to report that the Conservatives are up to no is actually more complex than our self-congratulatory good again. And, this latest attack on Medicare may end up visions. Yet, there is much to admire and honour in our being the most difficult to defeat yet. Unlike the last time, they health-care system. Which is why we need to understand are not putting out a clear plan or package. Instead, they are the risks to Medicare and consider options that can build, dribbling it out in pieces — some cutbacks to seniors’ benefits rather than undermine, it. Hence, this issue. here, some opening of doors to private insurance there — The Friends of Medicare’s David Eggen starts us off by and before you know it, we are on our way to an American- offering an account of what the Conservatives are up to style system. these days and how we can mobilize to stop them. But we all know that stopping them isn’t enough. So, Jason But we should not get caught in the trap of defending every- Foster examines some of the big ideas — some smart, thing about our current health-care system. Medicare is in some not-so-smart — that could reform Medicare. need of reform, but it needs to be the kind of reform that improves and expands health-care access for Canadians. Tom Fuller highlights an under-reported risk to health care - the rise of superbugs and how government cutbacks increase the risk. We have to talk about the threats to it, but also what else we can do to strengthen it for the 21st century. That is the conver- Showing us how we can all make a difference, Samara sation this issue of Union hopes to start. Jones interviews a Hinton woman who has committed her life to advocating for seniors. In a second piece, she Enjoy your reading. takes a look at health-care systems in Europe. Jim Selby has us look back at the political origins of Medicare to remind us of what we can achieve together. Gil McGowan President The issue also continues Michelle Westgeest’s series, part of our Board Watch Project, examining the foibles of the Labour Relations Board.

Over the next few months, all of us will have to do our bit to help defend Medicare against further privatization. Hopefully this issue of Union will inform and inspire you in your efforts.

We hope you enjoy this issue of Union.

spring 2009 | union 1 The Stealth Attack On Health Care In Alberta david eggen

2 union | spring 2009 feature report

The Stelmach Conservative government has been making sweeping changes to Alberta’s public health system, but they’ve been doing their very best to NOT tell anyone about it.

Health and Wellness Minister Ron Liepert has basically admitted as much. He told the Edmonton Journal that the “third way” failed in part because it was unveiled as one entire package, vulnerable to criticism. “People were allowed to pick at certain things they didn’t like, highlight it and then scare government off, and there wasn’t the political will to follow through,” Liepert said.

It is interesting to note that Ron Liepert, a relatively new member of cabinet, before his election as an MLA worked on the Mazankowski report, which was the 2001 plan for privatizing health care and getting people to pay directly for health costs.

Liepert is considered tight lipped and tough talking. However, he has promised to “unveil a new model to ensure delivery of health services is more effective and efficient.”

Up until now, though, the government hasn’t been at all upfront about what the “new model” will look like.

In the midst of the radio silence, changes to health care have been coming hard and fast. Liepert lost little time in clearing the way by firing all the top brass in the province’s nine health regions and putting the whole system all under the new “superboard”, Alberta Health Services. It was revealed shortly after that the Board signed an agreement to do anything and everything the health minister says.

Liepert is always quick to say his plan is NOT health-care privatization, but he has never been quite able to say exactly what it IS. We need to look at some of the steps the government has taken in the past year.

Who’s On Board?

For example, who has Liepert appointed to his new superboard?

Ken Hughes, the chairman, is a former Conservative MP and a private insurance company owner and investor. Liepert picked Charlotte Robb as his first CEO and she came over from one of Alberta’s largest private health corporations, Dynalife, the diagnostic giant.

When Liepert and Hughes announced their hand-picked board members in November, almost all of them were business people with little medical experience. Except of course Tony Frances- chini from Stantec, the engineering company that has many contracts with the health regions. Another member, Jim Clifford, is in New Jersey where he has been working for private American health-care companies.

spring 2009 | union 3 putting the squeeze NDP Leader Brian Mason told the Journal that the people on alberta’s nurses picked for the Board were “the clearest signal yet” the government is going to an American-style private health-care system. The McKinsey Report (titled: Provincial Service Optimiza- tion Review: Final Report) was carefully edited. But one Multinational Companies thing it does openly talk about is how to deal with the Provide The Expertise nursing shortage. Huge multinational consulting corporations Deloitte and The report says the province is short 1,500 nurses now McKinsey & Company are clearly the planning brains behind which could grow to over 6,000 nurses short by 2020. It the changes in health care. The government commissioned a offers to address this shortage in the following recom- report from McKinsey that would be the blue print for health- mendation: “Deepen initiatives and incentives to increase care changes. productivity.” The report proposes “increasing the number of work hours required to earn benefits and replacing It’s clear that what he finally revealed – the “Service Optimi- part-time/overtime incentives with initiatives to promote zation Review” – was a carefully sanitized document. There full-time employment.” wasn’t any mention of McKinsey or who the authors were. It’s also clear that much more was taken out of the document. Yet In other words, make nurses work longer to get the ben- what remains is still quite instructive in terms of the govern- efits they deserve. How will that help attract and retain ment’s plans for health care (see sidebar). nurses during serious nursing shortage? Besides McKinsey, there was also a restructuring plan from Deloitte, who have an interesting approach to health care. At a recent health conference in Toronto, a Deloitte expert offered help protect medicare! up their analysis on the topic, “The need for disruptive change ! join the friends of medicare fight! in the health-care industry”.

Friends of Medicare is ramping up and preparing to cam- Few Albertans could have imagined bigger disruption than paign on alerting EVERY Albertan to what the Stelmach rapidly shutting down all the health regions and setting up the government is trying to slide through on health care. single superboard. There are petitions to be signed, leaftlets to be distributed and nearly 70 government MLAs that need to feel “Disruption also impacts sick Albertans who may be forced to the heat. Join in today... see our website wait more for care,” said Heather Smith, president of the United friendsofmedicare.ab.ca Nurses of Alberta. “We need a smooth flowing system and we call: (780) 423-4581 need changes to be smooth too, NOT disruptive.” or email: [email protected] Closing Rural Hospitals

Deloitte got $2.2 million from Alberta Health for a two-year audit of rural health facilities that created a shock wave with its recommendations to close rural hospitals. After the release of the report last June, Liepert was quoted in the Edmonton Journal saying that some small-town hospitals could be converted to walk-in clinics or seniors care centres.

4 union | spring 2009 But residents of small-town Alberta did not like the sound of that. “It’s one of the heartbeats of the community. It makes us a service centre and without that hospital we’ll have significant problems,” Athabasca Mayor Colleen Powell said in the same Journal article.

Cutting Benefits For Alberta Seniors Higher Drug Bills For Many Some of the harshest announcements from Alberta Health came just before Christmas. Liepert announced that NO new For another early Christmas gift, the government announced full-service nursing-home care beds would be built in the big changes to drug benefits for the province’s seniors. Seniors province for several years. This, despite the fact the govern- with incomes over $21,000 a year will have to pay the full cost ment estimates it is short 1,100 beds. Instead the government of prescriptions up to a limit that is determined as a percent- announced it would build more “assisted living facilities” age of their income. For seniors with lower incomes, all costs which offer little medical care unless the resident pays extra for prescriptions are covered, but a senior with an income of, out of pocket. This is a policy designed to allow the private facil- for example, $50,000 a year will have to pay for the first $660 ity operators to make extra profit by billing for “extras” that are of their prescriptions in a year. This attack on universality will part of basic care in a nursing home. affect thousands of seniors who previously paid a minimal co- payment on their prescriptions. The report even sug- gested taking seniors This attack on Vision 2020 And “Patient-Focused” Services out of nursing homes universality will affect and, “with support,” thousands of seniors Late in December, the government released “Vision 2020,” their putting them back who previously paid a outline for health services in the future. “Patient-focused” has in their houses or minimal co-payment on been stuck as a major motto on almost every document from with their families, a their prescriptions. the new superboard and it is an important clue in this guessing concept that shocked game. “Patient-focused” sounds great, but as any health practi- many. tioner will tell you, care has always been patient-focused.

The government has been also moving towards a long-term But, patient-focused has a particular meaning as explained care fee system (“variable accommodation fee structure”) earlier this year by health-care entrepreneur Dr. Brian Day: where government support or subsidy only applies after a senior’s money is virtually gone. Once the private provider “We believe patient-focused funding, where the money follows the has taken all the senior’s money the government may provide patient, will drastically improve the performance and efficiency and additional support. accountability of hospitals. … That introduces an internal market competition between the different hospitals to attract patients, so Last fall the Parkland Institute released a study by economist patients become a value, not a cost. I think you do need to introduce Greg Flanagan that shows a steady rise in the number of a competitive model and if that means changing the way the seniors in Alberta. Flanagan says this means constant growth (Calgary Health) region is structured so be it -- the reality is any in the number of seniors requiring long-term care and even full system that is monopolized in nature is not good for the consumer.” nursing home care. The government’s strategy is going to leave ( Calgary Sun March 29, 2008) many more frail elderly — and their families — wondering how to cope. A key component in “2020” is moving health services out of hospitals into what they call “short-stay, non-hospital facilities

spring 2009 | union 5 and other clinic-type arrangements as an alternative to hospitalization.” While the term “non- hospital facility” is new, it likely means private clinics and private hospitals like HRC in Calgary.

And of course, the government will encourage those who want to pay more for better or faster services to do so through the network of private clinics that will bill both the patient and Medi- care for their services . It’s already happening now with the Copeman Clinic in Calgary. Liepert says there is no problem with this.

The Costs Of Health Care

The provincial government is trying to have it both ways. They harp about health-care costs being out of control. Then they say the changes are not really about saving money. They can’t say these changes will save money because in fact they know it will cost both the public purse and all our personal “purses” much more.

The superboard deficit already seems to have mushroomed from of around $100 million to something over $1 billion in just a few months.

And now with the economic downturn, we already see the Conservatives threatening “Klein-era” cuts. They may use their new fiscal difficulties as an excuse to ramp up their health-care reforms, shifting more costs from Medicare to your wallet.

There are better ideas to reform Medicare to make it work more effectively AND more cost efficiently. But the Conservative government has no interest in exploring those ideas. If we are to consider pharmacare or universal homecare, it will have to be Albertans who put it on the agenda.

Who Asked For This?

During the 2008 election, Stelmach reassured Albertans that the “third way” — Klein’s last try at privatization — was “DOA.” That is supposed to mean “Dead On Arrival.” Yet for Stelmach it seems to mean “Do Over Again”. Their actions of the last few months indicate that despite their silence there is a very clear and dangerous agenda afoot. We have only seen glimpses of it so far, but those glimpses point in a very clear direction.

Don’t be fooled by soothing phrases and clusters of seemingly innocuous announcements. Their cumulative impact means a serious and direct threat on our Medicare system.

The good news is that Albertans have stopped health-care privatization three different times in the past 10 years. We can do it again. We need to mobilize and to organize to make sure the government has to backtrack once again.

6 union | spring 2009 feature report fixi ng medicaare Picking the Right Mechanic jason foster

ew people are content with the current state of our health-care system. There is no question it is under Fstress and that our almost 50-year old institution is in need of some repair. And like any repair job, finding the right mechanic is one of the most important questions. There is no shortage of suitors for the job of health-care repairman. Yet how are we to separate the whiz kid from huckster? Which ideas could work, and which will only make matters worse for Canadians looking for reliable health care?

There are many ways to tinker with Medicare, but only some of them will get it run- ning again smoothly. Here are a few that may have crossed your path. ✗ Encourage Boutique Medical Clinics Some argue that we need to offer more choice to patients and allow doctors to package services in such a fashion that they can combine traditional acute care with other preventative services. They can cater to executives and other with financial means to free up space in more traditional medical practices, thereby increasing access for all people. These “boutique clinics” offer a solution to Medicare by both increasing patient choice and acting as a pressure valve for the rest of the system.

As an example, last fall, the doors opened on the Copeman Clinic in Calgary. At Cope- man, for an initial fee of $3,900 and annual payments of $2,900, patients can get

spring 2009 | union 7 guaranteed quick access to a doctor and an array of diagnostic, of medicine. Canadians want access to health care when they assessment and diagnosis services from a team of health pro- need it, not the right to pay for a battery of tests and proce- fessionals. The Clinic portrays itself as offering “preventative” dures of uncertain medical value. health services as a supplement to basic health care. In addi- tion to the patient fees, Copeman bills Medicare for essential A more valuable solution might be to put the health profes- services provided. sionals employed by the boutique clinics back to work fully in the public system, where they will see more patients On the surface, this may seem like it solves two problems at once – offering more choice and reducing pressure on the rest Expand Role Of Nurse Practitioners of the system. Unfortunately, it solves neither. ✓ And Other Health Professionals

In terms of reducing pressure, a research study released in fall A more reasonable direction to increase access to basic health of 20081 found that these clinics contribute significantly to care might be to expand the role of nurse practitioners (RNs physician shortages with additional training to allow in the public system. They them to perform many physician draw doctors from public prac- As for patient choice, these clinics functions) and other professionals tice and offer them caseloads foster the myth that health care is (social workers, physiotherapists, that are one-third to a quarter a commodity like any other. Choice counselors, dieticians, technicians, of standard practices. Simi- is an important concept for buying etc.) in delivering direct medical lar problems are found with a car or choosing a brand of cereal, care. other health-care profession- but it does not appropriately apply to als. These professionals treat a health care. In many respects doctors are the smaller number and narrower bottleneck in the health-care range of patients— patients system. There are too few of them who are often healthier, due to and their fee-for-service model their economic status, than is restrictive, creating long waits the population as a whole. for many procedures and treatments. Many argue care is most effective when a range of professionals work as a team, These clinics also play fast and loose with the Canada Health offering a coordinated compendium of services to patients. Act. “Many of the boutique physician clinics co-mingle med- Consequently, their idea is to foster interdisciplinary teams to ically-necessary with unnecessary services in an attempt to provide more thorough, more timely care. sidestep the Canada Health Act’s prohibition on two-tiering.2” In Alberta, the Conservative government has turned the nurse As for patient choice, these clinics foster the myth that health practitioner model on its head. It has forbidden them from care is a commodity like any other. Choice is an important joining unions and is establishing a doctor-style fee-for-service concept for buying a car or choosing a brand of cereal, but it payment system for them. The government is trying to make does not appropriately apply to health care. Canadians are nurse practitioners the new health-care entrepeneurs, opening not looking for a range of health services; they want the right their own private clinics. treatment to cure their ailment or prevent disease. Plus, a regular marketplace assumes the consumer has the ability to However, properly implemented, a team model, led by nurse inform themselves of the merits of the choices. This is simply practitioners, has the potential to greatly increase access to not feasible in the complicated, technical and sensitive area care AND reduce costs at the same time.

8 union | spring 2009 feature report

a sampling of alberta’s private, for-profit health clinics

Alberta has 31 private, for-profit clinics, most of which receive money from Alberta Health. Here is just a sample of them.

Boutique Clinics: • Copeman Healthcare Centre (Calgary) • Dominion Medical Centres (Edmonton) One of the innovations of the boutique clinics is to offer wholistic care that focuses on prevention. Why should this MRI/CT Clinics: good idea be restricted to those who can afford to drop three • Mayfair Diagnostics (Calgary) or four thousand dollars? If we implement a similar model in • Canadian Diagnostic Centre (Calgary) public facilities, its advantages can be applied to all. • Medical Imaging Consultants (Edmonton) • Insight Medical Imaging – Meadowlard Allow Private Clinics to Wellness Centre (Edmonton) ✗ Access Public Funds • Open MRI/MYK Imaging (Calgary) • Central Alberta Medical Imaging Ltd. If boutique clinics are a concern because they siphon key (Red Deer) resources (staff, resources, etc.) from the public system, maybe we can resolve it by allowing private clinics to fully participate Surgical Facilities: in the public system by billing the government rather than the • Mitchell Eye Centre (Calgary) patient for their services. • Health Resource Centre (Calgary) • Sante Surgi-Centre and Vein Clinic This is a rapidly growing model for Medicare. Proponents argue (Medicine Hat) this saves money and reduces waiting times, as the govern- • Alberta Surgical Centre (Edmonton) ment does not have to invest in costly infrastructure, and the • Surgical Centres Inc.(Calgary) private clinic is more likely to stay up to date with technology • Gimbel Eye Centre (Calgary & Edmonton) and techniques. A recent study found that there are 130 private • Holy Cross Surgical Services (Calgary) clinics operating in Canada and the vast majority takes both public and private funds.

This proposal neglects the fact that there is a limited number of health professionals in Canada and that the growth of private clinics only draws doctors, nurses and technicians from public facilities – which means waiting times are not reduced, only moved. More importantly when examining the costs of governments paying for-profit operators to deliver health care, “researchers found health spending was higher and increased faster in communities served by for-profit hospitals compared to non-profit communities.”3

spring 2009 | union 9 Also, for-profit clinics often offer “upgrades” or “enhance- strophic” care, but other services could be moved to this model. ments,” directly billed to clients, that can be hard to restrict. MSAs could also be used to pay the premiums for private Why get that rusty old government-issue hip when you can health insurance. get a fancy titanium-alloy, kryptonite-coated hip for only a few hundred dollars more? This model is seen as a way to increase individual choice and autonomy, while managing costs for the government. It In many respects, sending public patients to private clinics also finds a way for Albertans to purchase health insurance serves to only create a captive market for these health-care independent of their workplace, as only a small percentage of entrepreneurs that they can upsell other products. workers have workplace insurance plans. Second, proponents argue it will facilitate efficiency and productivity among health More damning, evidence suggests that private clinics are LESS facilities as they compete for patients. efficient than public clinics. In the past few years the Manitoba NDP government had a policy of quietly buying up private clin- The proposal falls down on three fronts. First, it, too, builds ics and returning them to the public fold. Plus it has prohibited upon a marketplace assumption, where free agents make ratio- private clinics from both billing publicly and privately. Due to nal choices using best information. It is simply not possible in its policies, Manitoba has only two for-profit clinics (that have health care. Information is too hard to gather, and the reasons so far refused to sell to the government), compared to Alberta’s for accessing health care (i.e. ,illness) are not times when a con- 31 (see sidebar). sumer is able to make rational, carefully considered choices.

In 2001, Manitoba bought the Pan-Am private clinic which now Second, it inappropriately applies an RRSP model to health care. operates as a public facility with no extra fees. The number Medicare is like a defined-benefit pension plan – you pay in of procedures out of this state-of-the art clinic has more than with your taxes and when you need health care, you are guar- doubled since it entered public hands, and the cost per proce- anteed a certain level of care. MSAs flip that around, giving you dure has dropped. Showing that non-profit, public health care money upfront but making no guarantees of any level of ben- can get more done. efit. How do you know that you have enough money in your MSA to pay for that laser eye surgery? Or that physiotherapy? ✗Have the Money Follow the Patient In short, you don’t. There is a lot of talk these days about “patient-focused” health Third, the proposal is designed to create more space in health care and about the concept of having the money follow the care for private insurance companies and for-profit clinics. And patient, regardless of where they go. In the parlance of its as we have seen, that leads to greater privatization, higher costs proponents, “patient-focused” means putting the interests of for both government and patients, and unequal access to medi- patients first and allow them to choose how to spend it. cally necessary health care.

In one regard this is an ideological relative of “patient choice,” Move to the of attempting to commercialize health care. However it is more ✓ “Second Stage” of Medicare than that. Ultimately, repairing Medicare might mean finishing the The most likely mechanism for patient-focused funding are original construction job. The best direction for the future of Medical Savings Accounts (MSAs). This is the model where Medicare may lay in expanding it – as was originally intended. the government, instead of paying for health services directly, provides money to every person who then uses that money Noted health-care policy expert, Dr. Michael Rachlis, has as they see fit. Usually MSAs are seen as a supplement to core recently been suggesting that the time has come to implement health care; the government would continue to pay for “cata- what he calls “The Second Stage” of Medicare. As Dr. Rachlis

10 union | spring 2009 feature report

explains the original vision of Medicare Ultimately, held by Tommy Douglas and his CCF gov- references repairing ernment was of a more comprehensive Medicare might program, both in what it covered, but 1. “Eroding Public Medicare: Lessons and mean finishing also in how it envisioned health and how Consequences of For-Profit Health Care the original it delivered health-care. Political reali- Across Canada”, Natalie Mehra, October construction job. ties (the doctors’ strike, opposition from 2008. The best direction other provinces) forced Douglas to put 2. Ibid. p. 47. for the future of off the second stage. 3. “Mythbusters: For-profit ownership of facili- Medicare may lay ties would lead to a more efficient health in expanding it – Rachlis is arguing we need to re- care system”, Canadian Health Services as was originally structure health care delivery and our Research Foundation, 2004. intended. approach to illness and health. He 4. “We Must Go Forward”, T.C. Douglas, in sketches out what the second stage Medicare The Decisive Year, Lee Soderstrom might look like. It includes: (ed.), 1982. • Expansion to include pharmacare, dental care and universal home care; • Moving away from physician fee-for-service and toward salaries for doctors; • More coordinated, community-based care, provided by teams of health- care professionals; • Focus on wellness rather than sickness; • More community, democratic control over health care provision;and • Focus on equity – how to reduce disparities in health outcomes among populations

The model addresses many things simultaneously. It addresses the pressure points currently experienced by Medicare and it effectively elimi- nates the growing risk of privatized, for-profit medicine.

Plus, it will lower costs while making people healthier. In Tommy Douglas’s own words: “All these programs should be designed to keep people well – because in the long run it’s cheaper to keep people well than to be patching them up after they are sick.” 4 (Douglas, 1984)

spring 2009 | union 11 interview with Q? lynda jonson Creek, that there were other issues besides staffing shortages, food issues (including low-quality food, food was being brought A! by samara jones in from other towns, served cold, etc.) and we heard stories about systemic abuse and neglect because the staff did not have time making sure that for toileting, bathing, or even the time it took to adequately feed the residents. The staff was just so overworked.

What we witnessed was just unreal. someone Union – What did you do after you’d witnessed the terrible conditions in nursing homes across the province?

LJ - We took 4,800 petitions to the legislature to ask for increased staffing levels. In January 2003, Premier Klein dismissed cares what we had witnessed. And then in May, the Auditor General’s The Fight For Long-Term Care report came out and verified what we had seen.

Union – How did you become an activist for seniors’ care? Union – What do you think was the cause of the deteriorating level of care? Aside from the obvious cutbacks and staffing… LJ - My mother-in-law had been placed into facilities in Barrhead and Edson because there was no long-term care centre in Hinton. LJ – The conversion of long-term care facilities to designated When the Mountain View Centre, which had 25 long-term care assisted living facilities. These conversions mean that there are beds plus 27 supportive living unit facility opened up for resi- inappropriate levels of care for many residents plus inadequate dents in Hinton in October 2002, we brought my mother-in-law government funding for sufficient skilled staffing and programs back home to be close to her family. to meet the needs of residents. Also, low staff wages have re- sulted in high-staff turnover. During her stay in Mountain View Centre, Mother became ill with Clostridium Difficile. It was during this time that I saw the staff There are not adequate care standards, funding, inspections and shortages. I lived at the facility full time, caring for her, night and enforcement of facilities.

day, until her death. I didn’t want the staff to get sick or pass the People are not able to get the care that they need because there infection onto other vulnerable patients. is a shortage of palliative care expertise and funding that has When my mother-in-law passed away, I vowed to work hard to caused unnecessary suffering for patients who are dying.

increase the staffing levels in these facilities. From our experience we’ve seen that many complaints from Union – What did you do first? residents and families are not being investigated.

LJ - My husband and I started touring Alberta to see if it was the Union – The long-term care facility in Hinton was converted to same all over the province, or just our facility. It wasn’t long be- a designated assisted-living facility. When did this happen and fore we found out, as we traveled from Grande Prairie to Pincher what impact did it have on your community?

2004 2005  Lynda’s Struggle Dec. 21— Attended town Jan—Received letter from Iris council meeting and asked Evans and a statement that For Seniors’ Care for support in not converting she is in favour of assisted liv- the facility in Hinton to an As- ing, claiming that the people time sisted Living Facility. of Alberta have requested this line type of housing. Aug 9 — Went to sessions for MLA Task Force group in the Barrhead hospital. 12 union | spring 2009 feature report LJ - The conversion of the Mountain View Centre happened in Union – What did you do to draw some attention to the issue? 2005 after only two years in operation. Ron and I tried to stop the LJ - I’ve tried to get action taken on complaints made by the conversion because it would mean a dramatic drop in the quality families of residents and the residents themselves. I’ve seen of care. In designated assisted-living (DAL) facilities, there is not many ministers - Minister of Health, Minister of Seniors, all of a registered nurse on duty 24/7 them. I went to see Iris Evans in person when or physician oversight and there It is clear that our elderly will she was Minister; I wrote letters to our MLA, are lower staffing levels and be paying – at the facility in to the Aspen Health Region, to Ministers Dave programs. At the time there were Hinton they already have Hancock, Ron Liepert, Yvonne Fritz, Premier no government standards for DAL to pay to furnish their own Klein, Premier Stelmach, and to the Ministers and our low-income residents rooms by supplying their own Greg Melchin and MaryAnne Jablonski. I had a lost their subsidies. beds, sheets, towels, toiletries, response from Melchin – his letter stated that The conversion has devastated pay 30% of their medication, the residents are getting the appropriate level the community. The staff is still purchase their own oxygen, of care. Lots of meetings and calls and letters trying to provide quality and dressing supplies and – but the government hasn’t taken action. compassionate care, but the supplemental diet. staffing levels are so low that the health, safety and well being of the residents are at risk. The staff must clean rooms, serve food, as well as to take care of 10 or more residents.

Union – How can this be allowed to happen? Are there no inspections of the facilities?

LJ - The community also wondered how this could have ever happened or was allowed to happen. The community raised funds and lobbied this government over 10 years to get a much-needed long-term care (LTC) facility built.

The worst thing is that the government did not monitor to ensure that residents were receiving the appropriate level of care after the conversion. There was no oversight or tracking of residents care. These were the same residents – these were long-term care patients who were all of sudden assisted-living residents over night. Their medical care needs did not change but the quality of care sure did.

2006

Sept. 7 — Met with the Min- Nov. 28 — Made a speech Jan. 13 — Talked to Human Feb. 23 — Went to vigil on the ister responsible for Seniors, on the steps of Legislature Rights Commission, they parliament step to stop the Yvonne Fritz, for the release of in Edmonton; Ray Martin, sounded like they were for Third Way. Ralph and Iris came the Task Force report. NDP MLA, presented 400 of the government and we did out with a reply to the Task our petitions to Legislature Nov. 8 -— Phoned the Health not have a case. Talked to Force with 36 million in funds Assembly. Minister to check if any prog- Ombudsman, his hands are to go to Long-Term Care and ress on the new standards had tied when it comes to private designated living facilities. been made. facilities, they are hoping to get some control in 2006; he gave us a name of a lawyer. spring 2009 | union 13 Union – How do the families feel? March 2008, and then we only got part of the report - they said for reasons of confidentiality we couldn’t have the whole report – LJ – The families are very upset and frustrated. we did find out that the facility had lost their licence for a while. Union - Can you tell me about the protest? And at the most recent family council meeting in November LJ - In May 2007, the families of the residents organized a protest 2008, we heard same complaints. Alberta’s weak inspection and on the sidewalk outside the facility. Families were concerned enforcement system raises serious questions and concerns. about low staffing levels, food and the cleanliness of the facility Union - What needs to happen to provide appropriate and and lack of fire drills. quality care? For example, beds hadn’t LJ - Strict regulations and been changed for three The government has to stop converting standards need to be enforced weeks; rooms hadn’t been facilities from long-term care to designated- to meet the needs of each cleaned for over a month. assisted living. It is unsafe for the residents. resident. Standards must be The quality of the food was The quality of care drops dramatically, the same for both the public inadequate for diabetics and and even the Auditor General said the and private facilities. We for residents who had trouble government must improve care and be able should have unannounced in- swallowing, plus many times to prove that residents' needs are being met, spections by an independent food was in short supply. and if not why not. body that has the knowledge, Union – What happened after expertise, and training re- the protest? quired to conduct a proper investigation. LJ - Over the summer, the problems got worse and the situa- If the facility cannot meet the requirements, it should first tem- tion deteriorated even more. So by fall, the families wanted porarily lose its licence to operate. And if things do not improve, something done. I phoned Aspen Health Region, the Ministry the facility should be handed over to the government, another of Seniors, the Health Minister and the Premier’s office, and an qualified operator or the community should have the option to investigation was launched. operate the facility. Also, the resident/family councils should be In December the operator of the Mountain View Centre met with involved in the oversight of facilities. the residents/family members and they apologized and made We need an Independent Seniors’ Advocate who is an officer of promises to improve the situation. Temporary staff was brought the Legislature. So that when anyone has a complaint it will be in from other facilities, but after a few months families started addressed, without people having to go through all levels of gov- asking me about the investigation. I had to chase up the report ernment. This is what happens now, and still nothing is done. from the Minister of Seniors office. We didn’t see anything til

2007

March 25 — Held a meeting May 18 — It is very hot and Jan. 22 — Wrote a letter to our April — Started Mountain with Iris Evans in the Edmon- they said they will not turn on new Premier Ed Stelmach to View Resident Family council. ton; made a presentation on the air conditioner until after get our long-term care back. how the third way has af- the May Long weekend. Copies sent to Ivan Strang, fected us with the changeover Dave Hancock, Greg Melchin from long-term care (LTC) to and Aspen Health Region. designated assisted living (DAL) by the Regional Health and Good Sam in Hinton. Iris promised to do a needs assessment by the region in Hinton. 14 union | spring 2009 Union - What do you think will happen if the government fails to This could have been very easily done in Hinton by reconverting make real improvements to the quality of care provided? the Mountain View Centre back to a long-term care facility. Our home-care staff would be able to work in the community where LJ – Our elderly and infirm will be dying from causes that could they are needed and the acute care beds in the hospital would be have been easily prevented. Our hospitals won’t be able to freed up. handle all our sick and aging population and there will not be appropriate Standards need to be in place re- or sufficient facilities. We took 4,800 petitions to quiring each DAL and LTC facility to the legislature to ask for more incorporate into its staff mix a nurse We are experiencing this in our staffing. In January 2003, practitioner with a specialty in the community already. Premier Klein dismissed what care of the elderly and disabled, plus I can see that the government is we had witnessed. And then the administrator should have train- not planning to make the necessary in May, the Auditor General’s ing in gerontology. improvements either, because they report came out and verified Union - Do you have any advice for are continuing to downgrade long- what we had seen. families or communities who are term care (LTC) beds and residents to facing the same problems? designated assisted-living (DAL) residents and beds. And this has to stop. For example, Jasper’s 16 long-term care beds are now LJ - First of all, you should join Public Interest Alberta (http:// gone. The LTC residents were moved over to a new DAL facility in www.pialberta.org). We have to be a voice for the elderly and in- October 2008. firm in the province. The PIA seniors’ task force is a key opportunity to band together to make a change. The care of our elderly is I visited the Jasper facility, the majority of those residents should a health care issue that should be fully covered under medicare, not have been moved to an assisted-living facility – it is a risk to so we need to support Friends of Medicare. their health, safety and well being. A few should actually have been placed in a palliative care unit. The cost of their care is now We, especially my generation, the baby boomers, cannot sit by passed onto the residents and their families. and be complacent. We need to fight for compassionate, digni- fied and appropriate care for our parents, grandparents, our Union – What needs to change? families, friends, and for all Albertans. LJ – Care has to start in the community. There must be the staff available and support services and programs in place to look after our seniors in their own homes. The government must com- mit to making quality home care available to all Albertans. And the facilities, at all levels of care must be there, when and where they are needed.

2008

May 12 — Held a Public Nov. 26 — Held a meeting at Dec. 28 — Phoned the September 18 — Met with Protest Forum on the street Mountain View Centre, things Ministers for Seniors and MLA Robin Campbell and a in front of the centre (Good got heated so they requested Health about the lack of town councillor in Hinton Sam); attended by more than that Lynda report the living staff, cooks and servers and discussed converting 40 people - residents, resi- conditions situation to the over the Christmas period. Mountain View Centre back dents’ families and friends. authorities to a LTC facility. Campbell This has now been three stated he would talk Ron years since the Auditor Liepert, Health Minister. General’s report to improve care conditions.

spring 2009 | union 15 g A w Cure for “Superbugs”? Clean Hospitals! tom fuller

hen people suffer from serious injury program is housekeeping – cleaning and disinfecting equip- or illness, they go to hospitals for ment, rooms and fixtures. treatment.W Ironically, however, hospitals and Last September, the Scottish government ordered health boards nursing homes are increasingly becoming a across that country to stop the contracting out of housekeep- source of disease. ing services in health-care facilities. The health minister, Nicola Sturgeon, announced the move as part of a campaign against Across Canada medical experts are sound- HAIs. Speaking to a conference of the Scottish National Party, ing the alarm about hospital-acquired Sturgeon said: infections (HAIs), which strike over 200,000 “On Monday morning, a letter will issue from my department Canadians each year, and cause at least to all health boards advising them that from now on, there will 8,000 deaths. Especially troublesome are be no further privatization of hospital cleaning and catering the so-called “superbugs” – diseases that services anywhere in Scotland… The public must have confidence have developed partial or complete immu- in their NHS (National Health Service) and know that they’re nity to antibiotics. going to get the best possible care whenever they need to go into hospital. That’s why tackling the problem of healthcare associ- The fight against these HAIs is conducted through the ated infections (HAI) is a key priority for this government.” infection- control programs in hospitals and other health care facilities. What many people, and most politicians, fail to These hospital-acquired infections pose a real and growing realize is that the foundation of any effective infection-control threat to patients and health care workers. Elderly Albertans

16 union | spring 2009 burning issues

the hai “big three” living in seniors' care facilities are especially vulnerable, because they may have weaker immune systems, and because infection-control procedures I. The HAI “Big Three” may be less vigorous than in hospitals, especially in the case of private for- MRSA – Methicillin-resistant Staphylococcus profit nursing homes. aureus. These bacteria live on the skin and on equipment, fixtures and other surfaces in The link between hospital cleanliness and HAI incidence is well estab- health-care facilities. When they infects the lished, as is the conclusion that investment in housekeeping is one of the body, the resulting symptoms can include boils, most cost-effective ways to prevent HAIs. A 2001 study concluded “a high abscesses and, in extreme cases, pneumonia standard of hygiene should be an absolute requirement in hospitals. In the or necrotizing fasciitis (“flesh-eating disease”). long term, cost-cutting on cleaning services is neither cost-effective nor Since it was first reported in 1995, MRSA infec- common sense.” tion rates have increased tenfold. Intensive cleaning procedures are required to kill this Of course, cost-cutting on cleaning services is exactly what happened to “bug.” Alberta hospitals in the Ralph Klein era, and the results have been pre- Cure for “Superbugs”? C. Difficile – a bacterium spread by contamina- dictable. Jane Sustrik, 2nd Vice President of the United Nurses of Alberta tion from fecal matter. According to Health (UNA) says: Canada: “The use of antibiotics increases the chances of developing C. difficile diarrhea “The real problem with hospital-based infections did not start appearing because antibiotics alter the normal levels until after the staffing cuts in the 90s. We need to ensure full complements Clean Hospitals! of good bacteria found in the intestines and of nurses in order to cut back on cross infections. The same applies for the colon. When there are fewer good bacteria, C. support staff, who do the cleaning and everything else. Good staffing, not difficile can thrive and produce toxins that can cutting corners, makes for clean and safer facilities.” cause an infection. In hospital and long-term- care settings, the combination of a number of There are a number of diseases that are easily spread through health- people receiving antibiotics and the presence care facilities in the absence of effective cleaning standards and infection of C. difficile can lead to frequent outbreaks.” control procedures. The Norwalk virus, for example, causes gastro-enter- Symptoms include diarrhea and potential de- itis. For most healthy adults this is an unpleasant experience but hardly hydration which can pose a significant threat life-threatening. For patients who are already ill, however, or for elderly to seniors in nursing homes or to hospital residents in a seniors’ care facility, the virus can pose a very serious health patients with weakened immune systems. risk. VRE – Vancomycin-resistant enterococci. Infec- tions can occur in wounds, the bloodstream or Of greater concern, however, are new strains of drug-resistant diseases. the urinary tract, but it can also exist in a “car- Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium Difficile, rier state” in the bodies of people who exhibit and Vancomycin-resistant enterococci (VRE). Because these “superbugs” no symptoms. Extremely drug-resistant, VRE have developed and continue to develop immunity to antibiotics, they are poses a threat mainly to those who are already a serious threat to patients and to health care workers. The UNA’s Jane weak or ill. Sustrik puts it this way:

“HAIs are a real concern to nurses… both for their patients/clients/residents/ and for themselves… Cutting corners and reducing staffing levels only increases the risks… We have seen the impact MRSA and VRE can have on a hospital population and health care workers. It’s the 21st century – we should be working to reduce risks and infections.”

spring 2009 | union 17 when superbugs escape The problem is that when health care budgets get cut, housekeeping often seems like an easy target for administrators. The risks associated with “superbugs” aren’t just limited to Doctors and nurses are high-profile professionals. MRI and CAT hospitals and nursing homes – these diseases are capable scan machines are high-tech and glamorous. Housekeepers are, of escaping into the community. In January of 2007, the by comparison, the invisible component of health care. Poorly Canadian Medical Association Journal warned of the paid and often ignored, they are often the first to experience dangers of community-associated MRSA, or CA-MRSA. In cutbacks and/or see their jobs contracted out. Contracting out, February of last year the Calgary Herald reported that the however, is a recipe for disaster. When Britain’s National Health incidence of MRSA in that city had almost doubled in the Service conducted an audit of cleaning in selected hospitals, it previous year, and had struck “marginalized populations in found that: the city: homeless people, drug users and prisoners.” The Herald report went on to say that “The superbug has “…where services One legacy of the gained an even stronger foothold in the United States, are contracted out Ralph Klein’s war on where the Journal of the American Medical Association they are more likely deficits has been, to estimated last fall that severe infections from the bacteria to have failed (the put it bluntly, dirtier killed about 19,000 people in 2005, taking more lives than audit). 20 out of 23 of hospitals. AIDS.” these hospitals which Source: http://www.canada.com/globaltv/natio...8- did not pass the cleaning audit are contracted out compared to aa24063e95f5 an estimated 50 per cent of contracts contracted out overall.”

Over the last 13 years, in hospitals and nursing homes across Alberta, housekeeping budgets have been pared back and, in some regions, housekeeping services have been contracted out. One legacy of the Ralph Klein’s war on deficits has been, to put it bluntly, dirtier hospitals. references The fight against superbugs begins with cleaning and dis- Prevention and Control of Hospital-acquired Infections, infecting our health-care facilities. The government and Special Report of the Office of the Auditor General of the owners of nursing homes should make investments in Ontario, September, 2008. housekeeping a major priority, and the contracting out of Rampling, A., Wiseman, S. Davis, L., Hyett, P., Walbridge, housekeeping services should be eliminated. A.N., Payne, G.C., and Conaby, A.J. (2001) Evidence that hospital hygiene is important in the control of methicil- This argument is especially important in the current economic lin-resistant Staphylococcus aureus. Journal of Hospital climate. With the province’s energy revenues dwindling, and

Infection, 49: 109-116. the possibility of budget deficits looming on the horizon, Ed The United Kingdom Parliament. 2002. Supplementary Stelmach’s Tories may be tempted to fall back on more cuts to

memorandum by UNISON (PS 33A). http://www.parlia- health care. If we’ve learned anything from our experiences ment.the-stationery-office.co.uk/pa/cm200102/cmse- since 1993, it’s that such a move would be a terrible mistake. Q

18 union | spring 2009

labour s n e relationssens non Labour Law Throughmichelle westgeest the Looking Glass

Alice curiously peered into the Looking- When dealing with the Alberta Labour Relations Board (LRB), glass House and wondered what it unions might be forgiven if they sometimes think that they, was“ like there. The Looking-glass House like Alice, have entered some backward Wonderland where the rules of logic have been reversed. At the LRB, it is often the appeared similar to her own but different opposite occurs of what one might ably expect. somehow. When the glass melted away she discovered the Looking-glass House stood One such example is how the LRB handles cases regarding in a place where all things were backward. “reverse onus." Onus, or burden, of proof is a crucial legal con- She had to walk away from a thing to come cept that is to ensure that the correct party has to prove their case to win. It is usually the party alleging wrongdoing that nearer to it. Eventually Alice found herself holds the onus. outside, a pawn in a real life game of chess. As she traveled through the backward place Reverse onus is when the burden of proof is flipped to the in an effort to become a queen, she was defending party, because the nature of the information cannot greeted by all manner of nonsense... “ possibly be proven by the alleging party. Lewis Carroll, Alice Through the Looking Glass

spring 2009 | union 19 burden and onus of proof First Case: Direct Union Evidence Dismissed [2007] Alta. Lrbr Ld-027; [2007] Alta. Lrbr Ld-082 Burden of proof is an issue in all legal cases. In the criminal matters, the burden of proof is the well-known This is often the case in unfair labour practice cases. It is con- “ beyond a reasonable doubt” which connotes near cer- trary to logic to require a union to prove an employer’s intent. tainty. In a civil context, the burden of proof is a balance Rarely will the union have direct evidence of an employer’s of probabilities so that a party must establish their case intention. As only the employer possesses knowledge of its is more probable than not. The burden of proof must be intention, it is logical to require the employer to prove that met on any given point by the party who holds the onus intention. of proof. Generally, the onus of proof rests on the party who alleges as noted by the oft cited proposition, he who The Boardwatch project (see sidebar) has uncovered how the alleges must prove. LRB handles reverse onus, and how, in its world, up is down.

The onus of proof is particularly important in civil cases. The Boardwatch Project Where all else is equal, that is both versions are equally probable, the party without the burden of proof will be Boardwatch is a new database built by the AFL which cata- successful. logues all LRB decisions. It was created due to a deepening sense of mistrust of the LRB among Alberta’s labour move- There are also instances where a reverse onus of proof ment. The searchable database can generate reports based on arises. Reverse onuses generally exist where the informa- a number of criteria including subject matter, Code section and tion sought is strictly within the knowledge of the party Board member so unions can have a better understanding of subject to the complaint and the other party has no how the LRB approaches issues. It can also identify key trends reasonable capacity to prove the knowledge. in interpretation over time. The AFL will produce database reports for AFL affiliates and other unions. For more information, contact Tom Fuller at the AFL.

On March 9, 2007 the Canadian Union of Public Employees (CUPE) filed an unfair labour practice complaint with the LRB that alleged a revocation application brought by a group of workers of the Town of Didsbury was tainted by an anti-union motive on the part of the employer.

One of the main arguments in support of the anti-union motive was an alleged conversation where a manager made told an employee that his pay would increase if the union was removed. The Board conveniently dismissed the direct evidence of the employee involved in the conversation, suggesting CUPE has misinterpreted it: “It is entirely likely that a new employee like Mr. Johnston, unversed in labour matters, would understand the discussion at its simplest level: without the Union, he would keep more of his paycheque, and this could be equated to a pay increase.”

20 union | spring 2009 labour law

summary of second case Sometimes I’ve believed The Board continued to explain as many as six away all of the union’s objec- the facts the board’s finding tions and found the union’s case The person who initially The Board accepts the that impossible to be nothing more than sus- spoke to the Board Officer employer’s explanation left a note for the employer, the note was thrown out as picion, ordered the revocation but the employer argues no • the employer thought it was things ballot counted,, where the union’s knowledge of the certifica- a call from someone trying to bargaining rights which lost by a tion application previous to sell something. before breakfast the terminations. single vote. – The Red Queen While the employer cited The Board finds the employer work slowdown as the reason wanted to soften the blow On April 20, 2007, by letter to the Board, the employer admit- for the terminations in the and accepts that the employer ted that the conversation was as Mr. Johnston recounted and termination letters, new em- • is planning to shutdown the that the manager had in fact told the employee that revocation ployees were hired afterward production area of the termi- and operations continued as nated employees as soon as would result in a pay increase. CUPE had been right after all, usual. practicable. and they moved to have the revocation reversed. Yet in a Lewis The terminations were made The Board finds no issue with Carroll-like twist, the chose not to overturn the original revoca- on February 20 effective the the date of termination and tion application – the logical remedy - but instead ordered a date of the certification ap- accepts the employer expla- second vote, which was also lost by one vote. plication thereby barring the • nation for the choice which terminated employees from related to pay periods. participating in a representa- This is a prime example of the need for a clear reverse onus tion vote. consideration. Reverse onus would have protected the integrity Two employees testify that The Board finds the employ- of the process. Yet, the LRB is content weights the explanation of they saw the employer at • ees must be confused about a sophisticated employer more heavily than even direct evidence work late on the date of the the date and time. application. presented by the union. This ignores the logic of the relationship.

In this case, the LRB could have required the employer to prove its motive instead of simply respond with an alternative explanation. Instead, they were quick to dismiss the direct evidence of the employee so that a more unlikely scenario could be elevated. You couldn't deny that, even if you tried The Red Queen in Alice’s tale bragged about believing six impossible things before breakfast. This case suggests the LRB may have similar abilities in the realm of logical suspension. with both hands – The Red Queen Second Case: Circumstantial Evidence Is Evidently Insufficient [2007] Alta. LRBR LD-024

On February 16, 2007 the United Steelworkers applied for certification of a unit of 29 employees. The LRB Officer contacted the place of business and spoke to a manager. On February 19, 2007 the employer, apparently unaware of the certification application, terminated 10 employees effective February 16, 2007. The

spring 2009 | union 21 employer provided the terminated employees with notices that Third Case: Discrimination Does did not allege cause and cited work slow down as the reason Not Equal Antagonism for termination. The employer proceeded to hire new employ- [2004] Alta. LRBR LD-062 ees and continued the work formerly done by the terminated employees. The Public Service Alliance of Canada (PSAC) alleged the Canadian Corps of Commissionaires (Southern Alberta) dis- The employer alleged no knowledge of the certification appli- criminated against known union supporters through unfair cation until February 20, 2007 when the Board Officer again scheduling practices. To support its claim the union provided contacted the business. However, two employees testified that the LRB with statistical evidence revealing clear differences they saw the employer at work late with a number of office between union and non-union employees’ scheduling. While staff on February 16, 2007. The Board preferred the evidence of LRB noted the evidence as troublesome, it discounted it as a the employer and found the employees confused and mistaken, result of errors in the compiling of data. The Board commented: accepting, instead, a head-spinning collection of justifications “Even assuming the numbers were valid and the Employer for the employer’s ignorance (See table). was unable to raise valid reasons for the differences, the Union has not satisfied us the Employer knew who was or was not a To compound the confusion, the Board did find the employer to Union member and acted against those members.” have “constructive knowledge” of the application since a manager had been notified by the Board. They did rule the employer To the LRB cogent evidence of differential treatment along a had improperly altered the terms and conditions of employ- clearly divided line with union on one side and non-union on ment during a certification application. This ruling, however the other is not strong enough circumstantial evidence to infer did little for the fired employees or for the union application. that the employer knew who was a union member and who was not. Suspect terminations should require more than token employer explanations. By incorporating a reverse onus, other jurisdic- The power imbalance between employees and employers is tions require the employer to prove that the terminations were exasperated by the Board’s approach to proof in unfair labour not in whole or in part based on an anti-union motive. Some practice complaints. The Board pays lip service to unions while jurisdictions go further and require the employer to prove that employer reasons are preferred even where improbable to the the terminations were for cause. ears of the ordinary worker.

Other jurisdictions recognize the potential for employer abuse and remedy the problem by establishing a reverse onus. Reverse onuses have been in place in labour legislation since the 1970s. The Alberta Board is behind the times and behind It’s too late to correct employers. Not only is a reverse onus fair in the context of unfair labour practices, it accords with legal principles. The evi- it, when you’ve once said dentiary burden should rest on the party with the knowledge. a thing, that fixes it, and In Lewis Carroll’s story, Alice eventually found the end of the chess board and became a queen. Unfortunately in Alberta you must take the unions are still pawns in the labour-relations landscape. consequences.

– The Red Queen

22 union | spring 2009 international

The American Way Is Not The Only Way Europe provides more coverage for more people in public health care systems samara jones

hen Canadians are asked what dis- But there is another way. Although Canada already has tinguishes our country from our more private involvement in health care than most European southernW neighbour, our universal health- countries, Canada could look to emulate the high percentage of services that are publicly covered, including dental and care system usually comes up – perhaps long-term care. Europe also has excellent examples of national after hockey. pharmaceuticals programs that limit patents and reduce phar- As other articles in this issue of Union have demonstrated, maceutical costs. Europe’s social programs, poverty alleviation Canadians have worked long and hard to develop and protect and inequality rates are significant contributors to Europe’s our medicare system. And often Albertans have had to work good health outcomes and provide excellent models for Canada the hardest, because the provincial government has repeatedly tried to undercut the principles of universal health care that are So, where should we look in Europe? Some of the best examples the foundation of the Canada Health Act by bringing in more can be found in the northern European countries of Belgium, “American style” choice. the Netherlands, Denmark, Finland and Sweden.

spring 2009 | union 23 Though northern European models of public health care differ Primary care and preventive care are priorities in Scandinavia. slightly, the coverage provided tends to exceed that in our own For example, in Finland multi-disciplinary teams working in universal Medicare system. Several countries cover the medical publicly owned primary health centres guide patients through and non-medical costs of long term care; most countries have the different levels of care. Since the 1980s, Finnish doctors comprehensive pharmaceutical plans for prescription medicaare required to see their patients within three days and their tions; and while individuals often have to pay for a portion salaries are linked to their workloads; both of these innovations of their medical expenditure (usually under 20 per cent for a have reduced waiting times and improved access to GPs . visit to the doctor, etc.), the government reimburses the bulk of medical expenses. The “different models” of health insurance Long-term care is more comprehensively provided and cov- in Europe are not generally privatized models. For example, ered in Europe. Belgium and the Netherlands provide good Belgium’s health-care system may look different from Canada’s, examples of a well-organized, well-funded and well-regulated because the Belgian government contracts out the admin- system. For example, in Flanders, in the northern half of istration of the system to health co-ops (mutual societies). Belgium, the regional government provides long-term care However, there are no private, for-profit insurance companies. insurance with full or partial coverage for costs relating to The Belgian government pays for health care and the reim- non-medical long-term care, including professional care in bursements come from and are regulated as part of the public long-term care homes . In the Netherlands, long-term care is system. financed by payroll deductions and government funds.

? private or public? the public funding behind much of europe’s the government pays much lower salaries to its doctors, it can “private” health care invest much more than Canada does in health infrastructure Proponents of private health care often hold up some European which is what prevents waiting lists. The privatizers would have countries as examples, particularly France and the U.K., both of us believe that it is the parallel private component of France’s which have two-tiered systems like Canada. However, this ex- health care system that boosts France’s position in international perimentation with mixing more private provision and insurance rankings like those published by the OECD, when in fact it is has produced mixed results. simply due to sustained public investment in public-health-care infrastructure. While the reforms to the U.K.’s public National Health Service usually get bad press, the British government has made a When making comparisons with Europe, the privatizing pro- significant impact in tackling the issues of the public system. moters point to private hospitals. It is true Europe does have For example, the British government hired 45,000 health profes- private hospitals, but the vast majority are not-for-profit private sionals between 2002 and 2006 to work in the public system, hospitals run by charitable organizations like Caritas. In the which helped to both decrease waiting times and offset the Netherlands, for example, more than 90% of the hospitals are disparities caused by the private component of the U.K.’s health private, not-for-profit facilities. care program. sources:

France is often cited as the model of privatized health that Private is not the cure – Council of Canadians: http://www.profitisnotth- Canada should follow – by proponents of American-style health ecure.ca/documents/CMA/fs_European_07.pdf care, who think that a European example will be more palatable Snapshot of Health Systems – European Observatory on Health and to Canadian tastes. This example is a red herring, however. Health Policies: French doctors are paid, on average, about 40 per cent less than http://www.euro.who.int/document/e87303.pdf Canadian doctors (equivalent to $70,000 a year). So, because

24 union | spring 2009 international

While there might not be a perfect match – the perfect single references model that Canada should look to in Europe – most European public health-care systems should give Canadians and our 1. Diana Gibson, Changing the Landscape in the Health health-care policy makers something to think about. Though Care Affordability Debate, in Medicare: Facts, Myths, the various health insurance systems and approaches might be Problems, Promise, CCPA, 2007 complex, Europe clearly offers Canada a strong example of a set 2. Snapshot of Health Systems – European Observatory of public health-care systems that, even during the “reforms” on Health and Health Policies: of the past several decades, continue to provide high-quality http://www.euro.who.int/document/e87303.pdf publicly funded universal health care. Instead of looking to the 3. European Observatory - on Health Systems and south, where health insurance is very often linked to employ- Policy, Health Systems in Transition, Vol. 9, No. 2, ment, Canada should look to emulate the good examples of 2007 – Belgium Health System Review, Dirk, Corens Europe, where both more people and more care is covered by http://www.euro.who.int/Document/E90059.pdf the public system.

good examples primary care and public health policy Finland Multi-disciplinary teams working in primary care centres provide primary care, preventive care and public health services. Public health policy has been successful in reducing mortality and risk factors related to cardiovascular diseases.1

long-term care Denmark 80% - 90% of total placement costs covered by government. It takes an average of two weeks to complete an assessment of a patient’s needs and the waiting period ranges between a few weeks to six months.2 references 1. http://www.euro.who.int/document/e87303.pdf pharmaceuticals 2. European Observatory - on Health Systems and Policy , Health Belgium Systems in Transition, Vol. 9, No. 6, 2007, Denmark – Health System Compulsory public health insurance reimburses Review, Martin Strandberg-Larsen, Mikkel Bernt Nielsen, Signild prescription medications.3 Vallgårda, Allan Krasnik, Karsten Vrangbæk http://www.euro.who. int/Document/E91190.pdf 3. European Observatory - on Health Systems and Policy, Health Systems in Transition, Vol. 9, No. 2, 2007 – Belgium Health System Re- view, Dirk, Corens http://www.euro.who.int/Document/E90059.pdf

spring 2009 | union 25 From Sickness Insurance To Public Health Care Workers’ search for health protection jim selby

anada underwent its own industrial Early factories, mines and mills were poorly lit, unventilated revolution in the last half of the nine- and unsafe. Work days could stretch to 16 hours a day, six days Cteenth century and the early twentieth a week. Working men and women and their families lived in squalid tenement houses – often with two or three families century. In the rapidly growing industrial squeezing into a single apartment. With little in the way of centres like Montreal, Hamilton and Toronto sanitation or heating, a subsistence diet and unsanitary public and in the resource extraction towns in the water supplies, outbreaks of diphtheria, cholera and other dis- west, the burgeoning working class strug- eases were rife in working-class neighbourhoods. gled with primitive and brutal living and Family survival depended upon men, women and children working conditions. seizing every wage and non-wage opportunity that came their way, from working in factories to doing piece work at home to the youngest children scouring the train tracks for pieces of coal for heating.

26 union | spring 2009 labour history

In the absence of any dependable social safety net (there were Unions found sickness insurance a powerful draw among no public unemployment insurance, workers’ compensation, workers. In the early days of the Western Federation of Miners, From social assistance or health care programs), loss of work time who organized hard-rock miners and smelter workers in B.C. through sickness or injury had devastating consequences for and the western U.S., the union reportedly spent more time working people and their families. Workers could depend upon and resources on providing direct benefits to members than it Sickness their neighbours and kin to provide what support they could, did on collective bargaining. but loss of even a child’s contribution could compromise a family’s ability to survive. Provision of sick benefits became an increasingly important Insurance union benefit over time, so that by the end of the 1920s, for With the construction of the railways, the migration of masses example, 46 of 105 American Federation of Labour unions of workers in search of jobs meant that people could not even had a sick benefit. Some unions abandoned the direct union To Public depend upon kin or neighbours to help since workers could provision of sick benefits in favour of collectively bargained dis- well be working far from family and community. ability insurance. However, the instability of union recognition and the fragility of collective agreements prior to World War II Even with the advent of the workers’ compensation system, made this a risky endeavour. Health Care there was little relief, since workplace accidents were a minor cause of workers’ disabilities. There is evidence that up to 91 per Beyond Simple Survival: Workers’ search for cent of all disability was caused by sickness. Looking For Health Outcomes health protection Under these conditions, it is easy to understand why access However, finding ways to cope with the immediate disastrous to sickness or disability insurance was a critical benefit for financial consequences of sickness in working-class families working people. The question was how to get it. Although com- only helped them survive sickness monetarily – it did noth- mercial insurers provided such policies, most workers could not ing to allow them access to proper medical treatment or to afford the premiums. improve their health outcomes.

The answer, for most workers, was either With little in the way of There were creative efforts to deal with the the early trade union movement, com- sanitation or heating, problem. In the 1880s, unions and coal mine pany (employer) societies or fraternal a subsistence diet and companies in the Glace Bay area of Nova societies like the Independent Orders of unsanitary public water Scotia arranged to deduct mandatory premi- Foresters or Odd Fellows. supplies, outbreaks of ums from workers’ pay (a check-off) which diphtheria, cholera and were then allocated on a per-person basis From a worker’s perspective there were other diseases were to one of the local hospitals and doctors (at serious drawbacks to the employer (com- rife in working-class the worker’s choice). The check-off and fees pany) societies insurance. If you lost your neighbourhoods were negotiated between the union, employ- job for any reason, you were cut off from ers and doctors and provided workers and the coverage. And, at least with the early forms of company their families with unlimited doctors and hospital visits and insurance, most of the fees came from employee dues anyway. procedures.

Although the fraternal societies did provide competitive cover- Similar “check-off” systems became common among mining, age for members, access to fraternal organizations was an lumbering communities and by railway employers. The weak- issue. The Odd Fellows, for instance, would not accept Catholics, ness of the check-off system was that it broke down during Jews, women or others outside their narrowly defined member- industrial conflicts. With workers no longer receiving pay- ship criteria. cheques, the check-offs ended and workers and their families

spring 2009 | union 27 were left without health care. insurance…” The Commission recommended a plan that would cover all doctors’ services, hospitalization and drugs. However, Other forms of pre-paid health insurance were also tried. The when the province attempted to introduce a watered down Medicine Hat General Hospital (1889) in Alberta was the first version in 1936 (it didn’t include coverage for the unemployed), publicly built hospital in the Northwest Territories (Sask. and it was ultimately scuttled by a coalition of business organi- Alta.). Any citizen could purchase a “Five-Dollar Ticket” that zations and the medical establishment. Similarly, the UFA would guarantee them health services for a year. government in Alberta drafted a health insurance act that they used as a major platform in the 1935 election. When the UFA Doctors As Public Employees lost the election to the Social Credit Party of William Aberhart, the plan was discarded. It is not a huge step from the kind of “vol- untary” pubic health insurance practised Prior to 1945, most existing health programs by local hospitals like Medicine Hat to Provision of sick were run by non-profit insurance coopera- the idea of a community actually hiring a benefits became an tives made up of local groups of workers, doctor under contract. increasingly important churches, employers and farmers. These union benefit over time. consumer insurance cooperatives made Saskatchewan’s “municipal doctor system” both hospital coverage and treatment by began in 1910 when a small rural commu- doctors affordable to their members. nity paid a doctor $2,500 per year to provide medical services to all resident taxpayers. The government then amended the After World War II, the for-profit insurance industry began to Rural Municipality Act in 1916, legalising the arrangement. enter the health insurance field. However, there were still large Under this system, rural municipalities, villages and towns portions of the population without access to such cooperative hired local doctors, financed from local taxation, to provide schemes. medical services to their residents. Tommy Douglas, The CCF They could offer a doctor a salary or fee-for-service payments And The Birth Of Medicare for general medical care, surgery, maternity care, and public health work. During the 1930s, the municipal doctor scheme One of the priorities of Premier Tommy Douglas when the was adopted across the province and spread to Manitoba and Cooperative Commonwealth Federation (CCF – forerunner of Alberta. (By 1948, 210 local governments had contracts with the New Democratic Party) came to power for the first time in doctors under the scheme.) Saskatchewan in 1944 was public health care.

Similarly, the Union Hospital and municipal hospital care plans By 1947, the CCF had developed and implemented the Hospital pioneered in Saskatchewan (later spreading to Alberta and Insurance Plan which charged individuals $5 per year and fami- Manitoba) allowed rural municipalities, villages and towns to lies $10 per year for access to free basic hospital services. The pool their limited resources to establish and maintain hospi- government also initiated free mental and cancer care. tals. Municipal hospital-care plans provided payment for the hospital services from general revenues. However, Douglas had a far more ambitious program in mind – ultimately he thought to use Saskatchewan’s program to Meanwhile, the public demand for a comprehensive system of become “the nucleus around which Canada will ultimately health insurance continued to grow. In 1932, a B.C. Royal Com- build a comprehensive health insurance program which will mission on Health Insurance reported “an overwhelming desire cover all health services – not just hospital and medical care – on the part of the public for the introduction of state health but eventually dental care, optometric care, drugs and all other

28 union | spring 2009 labour history

health services which people require” (Speech to Sask. Legisla- when the Liberals won the 1964 election in Saskatchewan, they ture, 1961). left the system intact.

Douglas, from the beginning, had been counting upon finan- From Saskatchewan To All Of Canada cial support from the federal Liberals who had been promising a national health care program since 1919. Without federal And, as Emmet Hall, dubbed by some as the father of Medicare, support, the province could not afford to expand the Hospital wrote later to Douglas, “I think your greatest and enduring Insurance Plan. accomplishment was the introduction and putting into effect Medicare in Saskatchewan. If the scheme had not been success- However, it was the newly elected Diefenbaker Conservatives ful in Saskatchewan, it wouldn’t have become nation-wide.” who first enacted federal cost-sharing of Saskatchewan’s hospital plan – thus enabling Douglas to announce the introduction In 1965, at the urging of the federal New Democrats who of Medicare in 1959. (Curiously, it was also the Conservatives held the balance of power in Parliament, the minority Liberal who launched the Royal Commission on Health Services government under Lester Pearson passed the Medical Care chaired by Emmet Hall whose Insurance Act and report mapped out the national He [Douglas] thought to use Saskatchewan’s Canadian workers Medicare program eventually program to become “the nucleus around finally got a national adopted by the Pearson Liber- which Canada will ultimately build a Medicare system. als.) comprehensive health insurance program which will cover all health services..." There is still a long When Douglas launched way to go. There is no Medicare in Saskatchewan in 1961, just slightly more than half universal program for optometric care or prescription drug (53%) of all Canadians had any coverage in either a hospital care. Provincial governments continually try to control costs by insurance or medical services insurance scheme – equally split reducing coverage or providing inadequate facilities and per- between profit and non-profit plans. sonnel. Many medical services are uncovered. Doctors, paid on a fee-for-service basis rather than on salary and uncontrolled The problems with for-profit insurance plans, as the American drug costs are huge drains on health have found out to their dismay, are legion. First, deductibles care funds. actually pass on huge costs to the individual. Insurance companies place arbitrary limits on what procedures are covered, However, working people no longer have to check their wallets and, unlike governments who do that, the companies are not before getting a doctor to check their pulse. accountable to the public. Insurers typically penalize or refuse coverage to people who claim too many times (that is, people with serious health issues). Finally, even the most affordable plans are often too expensive for workers unless their employer pays part of the premium costs.

Despite the flaws in the private insurance schemes, business organizations, the private insurance industry, the Canadian and American Medical Associations and the media in Saskatch- ewan all viscously attacked Medicare, culminating in a 23-day doctors’ strike in July 1962. Despite the furore over Saskatche- wan’s social health care, the program was so popular that even

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